CHARLOTTE, N.C. — Halfway through every month, the Carolina Abortion Fund runs out of money.
The fund, which helps pay for abortions and related expenses, never has been able to aid all the people who request support. Before the Supreme Court overturned nearly 50 years of abortion rights last June, the fund turned away roughly 100 people a month. Since then, it has closed its phone lines on at least twice as many callers, and possibly many more.
Most of the hundreds of unanswered calls are from people seeking money to travel to North Carolina from states that have banned or severely restricted abortion. They are often parents of young children and living in poverty. They either have to scrounge for other ways to pay for their abortions, wait until the next month if they can, or carry their pregnancies to term.
“You can absolutely hear urgency in their voices, you hear people crying on the phone, you can’t not get emotional,” said Kristy Kelly of Charlotte, a hotline volunteer. “These are human beings with lives and this is not a piece of paper or legislation to them, this is affecting somebody’s entire life trajectory.”
The Carolina Abortion Fund is one of roughly 90 small organizations across the country that often serve as a last vestige of support for people desperate to terminate unplanned pregnancies. Though donations to these funds spiked after Roe v. Wade’s reversal in 2022, so did demand, as many states tightened abortion restrictions that forced people to look beyond — sometimes way beyond — their own states for abortion services.
Indeed, a full 60% of people who reach out to the Carolina Abortion Fund, or CAF, are given nothing. The vast majority of the other 40% receive just a fraction of what they need and a very small number of people receive full funding.
Monica, in a sense, was one of the lucky ones.
Just two days before the fund’s hotline shut down for the month in January, Monica got a return call from Carolina board member Omme-Salma Rahemtullah. Monica, whose name has been changed to protect her privacy, confided she was out of a job, had just left an abusive relationship and was struggling to make ends meet for her young kids.
“I just can’t do it again, I already have three and no support,” Rahemtullah recalls her saying.
Monica was about 13 weeks pregnant, too far along for a medication abortion. She had an appointment at the Planned Parenthood clinic in Asheville, N.C., the following week. But that was a 16-hour round trip from her home in a neighboring state that bans abortion except when the mother’s life is at risk. Her trip would require money for gas, lodging, food and child care.
But Monica was still hundreds of dollars short.
A flood of donations, a surge in demand
After Roe fell, most Southern states from Texas to West Virginia rapidly banned abortion. North Carolina, which permits abortion until 20 weeks gestation, became a haven for pregnant people throughout the region. Abortion seekers flooded the state, creating the largest rate of increase in abortions managed by medical providers in the country, according to the Society of Family Planning, which researches reproductive health policy and science. The organization was unable to collect data on self-managed abortions, which are conducted outside the health-care system. But separate research by the Journal of the American Medical Association (JAMA) shows they are increasing.
At a time when abortions plummeted in the United States overall — by 32,260 from July through December 2022 — they jumped by 4,730 in North Carolina, the third-highest total increase in the country, after Florida and Illinois, the society reported in April.
North Carolina Republican lawmakers introduced legislation this week that would ban abortion after 12 weeks gestation, a period of time during which the majority of abortions take place. Republicans, who have a veto-proof supermajority, are expected to bring the measure up for a vote shortly.
Like many abortion funds throughout the country, CAF also received an upsurge of contributions following the May leak of the Supreme Court’s draft opinion in Dobbs vs. Jackson Women’s Health Organization, the case that reversed Roe. In the few days after the leak, CAF took in one-time donations of $110,000, a startling increase from the $235 it received during the same week one year earlier.
But the money has not kept pace with demand. While grants and individual donations to CAF increased 41% in 2022 compared to the previous year, calls soared by 400%, according to the fund’s records. On Feb. 1 of this year, the hotline received 108 calls, a new one-day record that equaled two weeks worth of calls a year earlier. The money doled out to those callers depleted the bulk of CAF’s monthly budget, the records show.
“After Roe fell, the money was pouring in,” Kelly said. “But so were the patients.”
What’s more, ancillary costs have skyrocketed since so many abortion seekers now are traveling to North Carolina from across the South. Even before Dobbs, Southerners were more likely than others to cross state lines to access abortion. Since Dobbs, Southerners have seen the largest increases in travel time to abortion facilities — from average drives of less than one hour to more than eight across the Deep South, according to JAMA. Most states in the South have long banned telehealth abortion, so in-person appointments are necessary even to receive abortion pills.
Most women in southern Louisiana now have to drive more than 10 hours to obtain abortions in other states, said Ushma Upadhyay, a reproductive health researcher at the University of California, San Francisco, and co-author of the JAMA report. “Some have never left their state before,” she said. “They’re surviving on low incomes and can’t pay for travel, much less the overnight stay that’s needed. It’s just out of reach for many now.”
Women of color disproportionately affected
People who can’t afford to pay for abortions out of pocket generally have to piece together money to pay for the procedure or pills and travel expenses and to make up for lost wages. An abortion costs an average of $625 nationally, but that doesn’t include travel, hotel stays, meals or child care. For its part, the Carolina fund pays an average of $264 for an abortion and another $25 to $200 for other expenses. To get additional support, CAF asks its callers to reach out to other nonprofits.
Those who have the most trouble paying for abortions are disproportionately women of color, who more often than white women live in poverty in states that have banned or restricted abortion access. Access Reproductive Care-Southeast, an Atlanta-based abortion fund that serves people who live in or travel to Alabama, Florida, Georgia, Mississippi, South Carolina or Tennessee, reports that 81% of its callers are Black, 77% are on Medicaid or uninsured — indications of poverty — and 77% have at least one child. The Carolina fund does not keep similar statistics, but estimates that since Roe fell, half of its callers come from other states, most likely in the South.
“Even with Roe intact before bans started, there were a lot of states with plenty of citizens that wanted an abortion and could not get one because they could not afford it or because they could not travel to the location of a clinic,” said Kelly, the Carolina fund volunteer.
Nationally, three-quarters of abortion seekers have incomes below 200% of the federal poverty line, which is $60,000 for a family of four and less than half that for an individual, according to the Guttmacher Institute, a research and policy organization that supports abortion rights. Southern states have the largest Black population, the highest rates of poverty and the greatest number of abortions in the country — a perfect storm as legal abortion access dwindles across the region, said Rahemtullah, the Carolina fund board member.
“Roe falling is not a ban on abortion, it’s a ban on poor people getting an abortion,” she said.
The South provides more abortions, receives less money
The National Network of Abortion Funds had promised in 2020 to pour $10 million into the Carolina fund and four other funds in the mid-Atlantic region, a windfall intended to enable them to hire more staff and provide a higher level of support to callers. The funds received some of the money in 2021 and staffed up. But late last year, the national network said no more money was forthcoming because an anonymous donor reneged on its pledge.
The small abortion funds that dot America — and that provide crucial money to women in desperate straits — are often overlooked by large philanthropic organizations that funnel the bulk of their grants to larger institutions such as the Planned Parenthood Federation of America and the National Abortion Federation. From 2013 to 2023, small clinics and funds like the Carolina fund received just 6%, about $37 million, of the $575 million that foundations earmarked for abortion work, according to a Fuller Project analysis of figures from Candid, a database of nonprofit grants. The Carolina fund alone would need $6.25 million — almost one-fifth of all the grant money that went to clinics and funds in the past decade — to fully fund abortions for the 10,000 callers who contacted the hotline in 2022.
More than half of the grants — $336 million — went to the big two: Planned Parenthood’s national headquarters, which uses some of the money to help fund its clinics around the country, and the National Abortion Federation, which represents independent clinics. Both organizations put money into the Justice Fund, which helps subsidize the cost of abortions for people who can’t afford them.
The grant total doesn’t include individual donations, which shot up in the past year. There is no database of individual donors, but piecemeal information from the largest organizations shows that they are relying less on grants from foundations and more on contributions from individuals than they have in the past.
The decline in foundation giving worries advocates on the ground whose cash-strapped organizations rely on that funding. Nowhere is the concern greater than in the South, which received just 9% percent of the $575 million in grants during the past decade, despite providing more than 33% of all abortions, according to the most recent data from the Guttmacher Institute.
The 40 volunteers who take the calls for the Carolina Abortion Fund live with that reality every day, especially when callers can’t pull together the money to pay for an abortion until they have missed the window for a medication abortion. The Food and Drug Administration has approved a pill regimen — now the subject of court battles — to end a pregnancy through 10 weeks gestation. After that, women must undergo a more expensive and invasive clinical procedure.
Monica, who called the Carolina hotline just days before it shut down for the month, was able to connect with Rahemtullah, the board member. Rahemtullah pledged to give her $200 for the clinical procedure. Separately they calculated that Monica would need about $200 for gas — now the biggest request from callers — $100 for a hotel and $75 for child care. With some money from the Justice Fund and $150 in her own cash, Monica said she’d be covered.
“One of my underlying fears, and one that we probably all face at [the Carolina fund], is that the donations will not keep up with the ongoing needs,” said Lucy Wilson, another Carolina volunteer. “A lot of people opened their pocketbooks in the immediate days post-Dobbs. But that initial funding is not going to stick around. And I really worry about what will happen moving forward.”
Editor’s Note: This story has been updated to make clear that when the Carolina Abortion Fund runs out of money halfway through the month, it stops doling out money to callers, but continues to refer them to other funds.
It came as little surprise to Donna Malkentzos when she ended up with asthma and rhinitis — these were common early outcomes for 9/11 first responders like her. At least it was covered by the World Trade Center Health Program (WTCHP), the federal government program that monitors and treats 9/11-related health conditions. Then, in 2013, she was diagnosed with uterine cancer.
Malkentzos assumed she’d get the same medical care from the WTCHP. After all, she knew they treated most cancers. But the program’s administrators delivered bad news — they said her uterine cancer wasn’t related to 9/11 exposure. She had the only form of cancer that the program refuses to cover, a decision which affects thousands of women who were around Ground Zero in the days following the attacks on the World Trade Center.
Finally, this summer, Malkentzos thought she would get that coverage. The Centers for Disease Control and Prevention, which administers the program, agreed this past May to add the cancer to its list of covered conditions linked to 9/11 exposure. But this decision has still not been enacted, and Malkentzos and others with uterine cancer remain in limbo.
“If they didn’t approve prostate cancer right away, I’d think it’s just the government moving slowly. But it only moves slowly for women it seems,” says Malkentzos, who now lives in Cape May, New Jersey.
The CDC changed its mind after a decade of lobbying by health care advocates, researchers, and patients that was covered last year by The Fuller Project. The government’s original reasoning for not including uterine cancer is they didn’t have enough data linking the disease to 9/11 exposure. But health care researchers say this is because the data collection for the program systematically overlooked women, and skewed heavily from the start toward issues that are more likely to affect male first responders.
There were less than 10,000 women in the program’s original cohort of 62,171 first responders and “survivors” — people who lived, worked, or attended school around Ground Zero. Their information formed the basis of its screening process, and as a result there are only 26,125 women like Malkentzos today among WTCHP’s 114,775 members. They make up only 23% of patients even though they comprise roughly half the program’s eligible population of about 423,000 first responders and survivors.
Health care researchers say this bias continues to haunt the program. Aside from the delay in including uterine cancer, female first responders and survivors with other illnesses that usually primarily affect women, like autoimmune diseases, are also left without federal support.
This kind of gender bias in data collection and analysis is systemic in health and science, says Irene Aninye, chief science officer at the Society for Women’s Health Research.
“The people making the decisions to open and close the doors, they don’t have the data that they need,” Aninye says. “Women need to be included in more studies, but data also needs to be analyzed with a lens of recognizing that they are small in number. And that’s a different mindset.”
“You cannot analyze small numbers the way you analyze big numbers. If there are 10:1 men to women in this project, the lens that you use has to be different… you’re not going to see the overwhelming trends that you’ll see for men.”
Aninye says studies frequently suffer from “gender-blindness” — failing to disaggregate and analyze variables by sex to suss out differences between men and women. In the case of 9/11, only 11 out of more than 1,200 research articles on the topic collected by the CDC are centered on women. Seven of them focus on pregnancy.
A golden ticket, just out of reach
Malkentzos has had two recurrences of her cancer. Over the years, she has needed chemotherapy, radiation, and surgeries, none of which were covered by the government. Because it’s not covered by the health program, she’s also ineligible for up to $250,000 in federal victim compensation for people with 9/11-related cancer.
“My wife is more bothered by the cancer than me,” Malkentzos says, “I’m more mad about the fight to get it covered.”
Entry into the WTCHP is the golden ticket to get a 9/11-related illness covered and treated by the federal government — everything from asthma to PTSD to most cancers.
The health program has its own physicians, records, and insurance program. Once you’re in based on a 9/11-related illness, you’re in for life. All preventive care, disease treatments, and follow-ups are covered, and the data collected is recorded to help the feds understand the ongoing health ramifications from 9/11.
With data collection heavily slanted toward issues that affect men, survivors who became sick later with conditions that mostly affect women have had a harder time proving their illness is related to 9/11.
Uterine cancer is the main form of endometrial cancer, and the most common gynecological cancer, affecting about 3 percent of women. There’s no official tally of uterine cancer among the Ground Zero population because no agency has researched it. Attorneys and advocates who’ve kept track estimate at least 50 cases. Based on the number of female survivors and first responders and the prevalence of the cancer in the general population, there’s likely thousands of cases.
The lack of federal program data on women today mirrors gender-blindness issues in New York City’s surveys to collect information on survivors and first responders, which informed the screening for the very first WTCHP cohort. Out of five surveys sent out by the city, only one asked specifically about women aside from questions about pregnancy status — a 2011 survey that asked a few questions about their alcohol consumption and their periods.
Living with fear
“From the beginning, I never expected much would come out of it based on how we’ve been treated,” says Patricia Grande, 79, who worked in an office building at Ground Zero. “All the focus was on first responders, and that left out most women.”
Grande developed uterine cancer in 2011 and never received any help from the federal government. She wasn’t able to get into the WTCHP because the cancer wasn’t a covered condition and, unlike Malkentzos, she wasn’t a first responder.
In remission now for 10 years, Grande, who still lives in Manhattan, doesn’t go a day without fearing the cancer is back. The stress is made worse worrying about how she would pay for it.
“Once you’ve had cancer, especially under these conditions of being excluded, every pimple, every pain, every scratch is another form of cancer,” she says.
Meanwhile, external research was starting to pop up that backed her case. Multiple studies released between 2014 and 2017 established links between endocrine disrupting chemicals (EDCs) and cancer, including uterine cancer. EDCs include the asbestos, heavy metal, and gasoline combustion found in Ground Zero smoke and dust.
After multiple petitions, a CDC committee specifically created for 9/11 studies recommended in Nov. 2021 that the health program add uterine cancer based on scientific research. Public comments and peer reviews were solicited and submissions completed by June — all were in favor of adding it.
Yet uterine cancer patients are still waiting. Different departments within the Department of Health and Human Services, a federal agency, and the CDC need to sign off on the new rule, even though the latter is part of the former.
“The petition to add uterine cancer to the list of covered conditions was filed more than two years ago, yet a prolonged bureaucratic process, in which government agencies have missed deadline after deadline, has prevented women from receiving the healthcare they need and deserve,” says Rep. Mikie Sherrill, a Democrat from New Jersey, a state that’s home to many 9/11 survivors and first responders.
The Department of Health and Human Services did not respond to multiple requests for comment.
Stephanie Stephens, a CDC spokesperson, told The Fuller Project the agency is still in the process of reviewing public comments and peer reviews.
Malkentzos, the retired NYPD detective, says she’s less worried about her recurring cancer and more concerned about taking care of her family.
While the federal government drags its feet, NYPD, her former employer, did declare her uterine cancer to be 9/11 related. This would make her wife, Jackie, eligible for benefits if Malkentzos dies from it.
“When I go, I want to go because of the cancer,” she said. “That way at least Jackie will get my pension.”
ATLANTA — As abortion clinics across the Southeast closed their doors this summer, one independent Atlanta clinic found itself expanding.
Independent abortion clinics — providers not affiliated with national organizations such as Planned Parenthood — operate at the very frontlines of the abortion battleground. “Indies,” as they’re called, make up only a quarter of all abortion clinics, but they provide more than half the abortions in the country. They are heavily reliant on abortion services for revenue, and over a third have shuttered since 2015 under the pressure of a record number of state regulations intended to restrict abortion. Twenty-six clinics closed down in the 100 days after Roe was struck down on June 24.
But this summer, Feminist Women’s Health Center was scaling up operations to meet a drastic surge in demand from states where abortion bans went into effect after the reversal of Roe v Wade, more than doubling the amount of patients they saw in July from the previous month. At the same time, staff were bracing for a potential existential blow themselves — a six-week abortion ban passed by state Republicans in 2019, previously blocked by a federal judge, was back in the courts. It would eventually be enacted in July, making abortion in Georgia close to illegal. The next month, the number of abortion patients who came to the clinic fell by half.
“We were contracting and swelling at the same time,” says Kwajelyn Jackson, the director of Feminist, as they’re known locally.
The chaos of the summer provides a snapshot into the extraordinary turbulence “indies” have been through in the past few years. Those that remain standing, like Feminist, are having to transform and expand the services they offer to survive as their primary source of revenue dries up. If they close down, even the abortions allowed within the bounds of current restrictions will be harder to access.
Feminist had seen Roe’s reversal coming and began prepping well over a year ago by launching a digital marketing campaign calling for people to come over to pick up some birth control.
“Sometimes people hear abortion [clinic] and birth control and they’re like, ‘Wait a second, what?’” says MK Anderson, development director at Feminist. “Believe it or not, we provide abortion care, but we [will] depend on wellness patients.” That means annual exams, screenings and contraceptives.
The health campaign served a dual purpose offering crucial reproductive healthcare services for the community at a time when abortion options were shrinking across the region, and opening up a new stream of revenue for the clinic.
Executing a pivot is rarely easy for a small outfit, but Feminist is trying to pull it off in an extremely unpredictable environment. When Roe was overturned in June, the clinic’s phone wouldn’t stop ringing. Pregnant people from other Southern states with tighter restrictions were looking for services in Georgia, where abortions were still allowed up to 20 weeks — the only state from Texas to South Carolina where this was an option.
Then an overlooked piece of legislation re-surfaced. The dormant regulations came into play, and a six-week abortion ban became effective overnight. With the count starting from conception, this gives women only about two weeks to get an abortion after a missed period. Clinic staff were forced to turn away patients who had traveled thousands of miles.
The past few months have been especially trying for the staff, who are trying to pull off a business transition while coping with increased workloads, shifting priorities, and an uncertain future.
Across the South and in rural areas, small health clinics are also stepping in to meet family planning needs. The difference, Jackson says, is “they don’t have anyone screaming at them with a bullhorn from their driveway.”
No time to process grief
Shaded by pine trees and tucked away on a residential street at the top of a hill, Feminist was founded in 1976 and has been a mainstay of the abortion access movement in the South for over four decades. Its discreet hillside perch is by design, thwarting persistent protesters at the edge of their driveway, keeping them far from the main entrance. But shouts, amplified by the bullhorns, still penetrate the building and seep into the examination rooms.
The clinic spends about $65,000 to $75,000 a year on security. But protesters still managed to enter the premises earlier this year.
Staff nerves were already frayed after years of fighting to stay open. Workers at independent clinics often choose the job because they are passionate about the work. Having to turn away desperate patients has left many feeling broken.
“I haven’t had a lot of time to process my own grief about what’s happening in this moment,” Jackson said. “But I am also not the person who has to look someone in the eye and tell them, ‘I’m sorry, we can’t see you today.’”
Feminist’s ultrasound technician of 25 years, Gloria Nesmith, has had to turn away dozens of patients since Georgia’s ban hit. At an October hearing on the state’s six-week ban case, she testified about the rollercoaster emotions folks go through as they wait to find out if they fall within the narrow window to get an abortion.
“I change out my tissue box more than I typically would ever, these days. We have more women who cry tears of complete relief, as well as from having to tell women they’re going to have to be referred to another state. Tears are normal but … I get different types of tears since the ban,” she said.
The clinic’s traffic dropped precipitously during the pandemic — from 5,000 patient visits to 3,000 — when many skipped annual check-ups and other routine care in 2020. Despite this, the clinic didn’t experience much of a drop in revenue from its services. That’s because patients were still coming for abortions; of those 3,000 patients, 85% came for abortion services.
Even if the clinic survives by offering new services, the six-week ban will deliver a major financial blow. Feminist charges between $518 to $1850 for abortions depending on type of abortion and gestation stage, compared to $100 for an annual gynecology exam. The clinic takes some insurance, but not Medicaid due to bans on federal funds paying for abortion, and offers sliding scale rates for low-income folks.
Feminist has benefited some from the surge in donations to the abortion rights movement in recent years. In 2020, it received almost $1.2 million in contributions, up from a little more than $1 million the year before. But the amount independent clinics like Feminist receive is a small fraction of overall philanthropy in this area. Of the $1.7 billion that flowed into reproductive health advocacy from 2015 to 2019, less than a quarter went directly to abortion access, as opposed to national political lobbying. Just 2% went toward funding abortion on the ground.
Instead, indies have been experiencing a rollback of support from national advocacy organizations since 2018, when the first tangible threat to Roe made its way through federal courts.
NARAL Pro-Choice America, the oldest abortion lobby group in the country, went from having local affiliates in 25 states to having offices in just three, looking to centralize its operations. Meanwhile, the National Abortion Federation, which spent $60 million to fund 100,000 abortions in 2020 and is the nation’s largest source of funds for women seeking abortions, has increased restrictions on funding for out-of-state patients, an important patient base for indie clinics.
Jackson knew the clinic would have to get creative to survive. When she became Feminist’s first Black director in 2018, she began plotting how to revamp the clinic’s mission.
The most dangerous place in America to be pregnant
For decades, those on the abortion frontlines in the South saw maternal and infant health outcomes worsen as the culture wars over abortion led to a broader rollback of abortion services in states dominated by Republicans. With hospitals closing down at unprecedented rates and prenatal resources shrinking, in tandem with conservative legislatures slashing health budgets, the South is the most dangerous place in the nation for pregnant people and babies: It’s home to the eight worst states for maternal mortality and the bottom four for infant mortality.
“The truth is, hospitals weren't offering the care, midwives were illegal, fertility treatment and access is not widely available. And now most people that are experiencing pregnancy are at a very high risk for being hurt,” says Erin Grant, deputy director of Abortion Care Network, a non-profit that provides financial support to independent clinics.
Jackson saw both an opportunity to make an impact, and a necessary business strategy. In addition to their existing pelvic exams and pregnancy testing, Feminist started to offer telemedicine, tubal ligation, trans hormone treatments, and in vitro fertilization (IVF).
The clinic is also trying to expand into prenatal services, with the goal of eventually becoming a birth center — on the face of it, an unusual journey for an abortion clinic, but a vital transformation that makes perfect sense to Jackson.
“We are really anxious to expand and to better serve trans women and intersex folks, really offer gender affirming care across the spectrum,” she says. “[That’s] something that's been demanded of us for a long time.”
The transition has allowed Feminist to stay afloat where many others have fallen. Jackson Women’s Health Organization — the organization whose case against Mississippi over its 15-week abortion ban was the vehicle used by the Supreme Court to overturn Roe — provided every abortion in the state for the past decade. The relentless demand the Mississippi clinic faced as the only abortion provider there meant they were not able to spare time and resources to execute a similar shift in strategy. When they shut down in July, it was a blow that reverberated for indies across the region.
“The only clinic in the poorest and blackest state in the country, of course they have focused their energy on trying to meet a need that feels unending. And when it’s ripped away from them, they don't have the investment to allow them to pivot in the ways that we perhaps have been able to,” says Jackson.
Feminist has no plans to close down, but survival is not a sure thing. For starters, it takes a dozen annual wellness exams to bring in the same revenue as one abortion. But the clinic has nearly paid off its mortgage, putting it on more stable financial footing. The organization is becoming a growing presence at the intersection of voting rights and reproductive justice in the South, hosting voter registration drives and legislative action days in the run up to the midterm elections. They are also one of the plaintiffs challenging Georgia’s six-week ban, with a ruling expected this month.
“It is critically important to me that this organization remain a beacon in the Southeast,” says Jackson. “What has happened in this country is going to take a long time to repair.”
The South’s abortion battle has a new front: telemedicine
How major abortion laws compare, state by state
AUSTIN—Nikita Kakkad is on her hands and knees, grabbing packs of condoms from a cardboard box underneath her bed, pregnancy tests and pamphlets from another. She divvies them up between a dozen or so plastic grocery bags, adds two boxes of Plan B — the most common “morning-after pill” — and then ties them up and stuffs them in her tote bag.
“Repro kits,” she calls them.
Kakkad is, technically, a 19-year-old rising junior majoring in biomedical engineering in her home state of Texas — a state where reproductive healthcare access has been on the chopping block for most of her life. On this Thursday afternoon in May, she’s also one of the dozens of young people throughout the country who serve as roving dispensaries of reproductive health products for those with shrinking options.
“You’re making a difference – for real,” one person texted Kakkad after receiving a delivery. Another wrote: “Everyone forgets how necessary all of it is until they need help.”
Just weeks before Kakkad’s sorting and bagging, a leaked draft decision from the U.S. Supreme Court made clear that a majority of justices were considering striking down the constitutional right to choose an abortion. The morning after the leak was first reported, Kakkad’s kit-request volume spiked: More than 70 students reached out wanting Plan B over the next two days. On Friday, the court made it official, voting 6–3 to overturn the 1973 landmark case of Roe v. Wade.
Kakkad is one of dozens of current and former students — Parteek in Northern California, Lauren in Chicago, Jasmine in South Carolina — in a nationwide peer-to-peer network known as Emergency Contraception for Every Campus (EC4EC) that distributes Plan B and other reproductive health products on 25 university campuses. With the end of Roe v. Wade in sight, these volunteers are redoubling their efforts to keep people of birthing age stocked up on products they believe are indispensable to their health and autonomy.
The work takes on a special urgency for student volunteers in the Deep South, where unintended and teen pregnancies are higher than anywhere else, but abortion options are quickly disappearing. These are the same states where reproductive health resources, such as sex education and birth control, have never been robust.
Experts and physicians also say the landscape is cluttered with too much disinformation and misinformation about different reproductive health products: Is Plan B effective? (Relatively.) Does it work for everyone? (No.) Are there more effective methods to prevent an unintended pregnancy? (Yes, but they require a prescription or in-person doctor visit.)
“I remember in high school just constantly feeling scared and like I had no idea what I was doing when it came to having safe sex,” Kakkad said. “I hope each time I deliver a kit, it helps people feel like they’re not alone.”
With tote bag in tow, Kakkad takes a 20 minute walk across the sprawling University of Texas campus and throws her wavy black hair into a bun before cooling off in earnest in the sterile, air conditioned hallways of a classroom building. Here, she finds the drop off point for the bulk delivery of the repro kits: a room in the sociology department littered with reproductive rights stickers and dog-eared data analysis textbooks. She stashes the kits underneath the desk in a waiting Trader Joe’s paper bag.
Earlier that morning, she’d gotten a ping from an individual customer at a nearby apartment complex.
“Left the kit by your door!” Kakkad texted. The exchange — free to the customer — was done in under 30 minutes, proving that Amazon isn’t the only service capable of same day delivery. But for Kakkad and other campus volunteers across the country it takes a daily miracle of logistics and gumption to pull it off.
The network was created in 2020 under the national non-profit American Society for Emergency Contraception that helps students set up hotlines and provides as much Plan B stock as they need. The group comprises reproductive health providers, researchers, attorneys and advocates that promote increased access to emergency contraception. Though the group spans decades in the field, their new EC4EC project works on a small budget — launched with a $90,000 philanthropic grant and individual donations to cover $1,000 yearly stipends to student volunteers, supplies and shipping. The Plan B doses — EC4EC has sent out about 600 over the past two school years — are donated from the drug maker.
Each campus uses its own system for communicating with and delivering to customers. Some, like Kakkad, use Google forms, promoted through Instagram, to collect bare-bone details from students requesting a kit — first name, phone number and address where they want the kit delivered. For added anonymity, students can also opt to pick up kits at a rotating campus pick-up spot, like the one at UT-Austin’s sociology department, which updates on the form users fill out. Others use a text hotline or partner with local reproductive service providers that get requests. The products are always free to the recipients.
This work, Kakkad said, becomes even more essential with the Supreme Court’s court decision to overturn Roe. The fear, she said, is that there are even more profound changes to come.
“It’s not stopping here. [Lawmakers] are going to take abortion away, then they’re gonna take IUDs away and they’re gonna take Plan B away. Then they’re going to take birth control away,” Kakkad said, firing off recent news articles about proposed bills to ban contraceptives. “You can’t believe in precedent anymore when it comes to stuff like this….Where does the line end? I don’t think people realize how drastic it could get.”
Kakkad’s advice: “We have to be even more proactive about getting long-term contraception.”
But which one?
Though IUDs are the most effective contraceptive, Plan B is still a powerful intervention to prevent pregnancy. Approved by the FDA in 1999, Plan B delays ovulation, averting potential fertilization, after sex. Since 2014 it’s been over-the-counter without age restrictions — and use has skyrocketed. Nearly a quarter of sexually active women of reproductive age used the morning-after pill in 2019, up from 11% in 2008 and 4% in 2002.
Despite its proliferation, barriers to access persist. It costs anywhere from $45 to $68, depending on the brand. And sometimes, even if students have the cash and are ready to buy it, it’s just not possible to obtain.
Nearly half of campus pharmacies report not stocking Plan B on the shelves, despite its over-the-counter status. And campus health centers aren’t always accessible — either located far from the campus-center, only open 9-5, or otherwise unreliable.
That’s why some universities, including University of California, Davis and Purdue University in Indiana, have stocked some on-campus vending machines with emergency contraceptive products.
“We want to increase access to care in any way we can,” said Michelle Szabo, the Purdue graduate student in charge of the project told the campus newspaper.
Access to products and services aren’t the only challenge for those seeking reproductive health care. Misinformation swirls around Plan B. In reality, Plan B, like hormonal daily birth control pills, prevents ovulation. But outdated information on the packaging label incorrectly claims it could prevent “attachment of a fertilized egg to the uterus.” That inaccurate language has been used as rationale to ban Plan B by lawmakers who want to codify life as starting at fertilization. Anti-abortion groups have successfully blocked access to emergency contraceptives on some campuses using that argument.
Plan B is also not for everyone, experts warn. The pill needs to be taken as soon as possible after sex and loses efficacy over time. It also doesn’t work as well for people who weigh more than 165 lbs.
“Plan B is not the most effective [emergency contraceptive], it’s actually the least effective. But it’s the most available,” said Dr. Mimi Zieman, an OB-GYN in Atlanta and author of contraception textbooks.
There’s still at least a 96.9% likelihood that it’ll work, and she points out that barriers to more effective emergency contraceptives are often higher. Ella, another morning after pill that prevents pregnancy by blocking progesterone production, is more effective than Plan B, at 97.9%, but requires a prescription. Ella is also more effective for heavier folks and can work up to five days after sex.
Having a copper or hormonal IUD inserted soon after sex is the most effective emergency contraception, at 99.9%, but requires an in-person clinic visit, a co-pay and an invasive procedure. Only about 30% of college campuses report providing IUD services.
Experts say having more options readily available is the best way to intervene on unplanned pregnancies, and another reason why EC4EC is pushing for vending machines across the country. Kelly Cleland, executive director of the American Society for Emergency Contraception, has worked on reducing barriers to contraception her whole career. She’s hoping that daily birth control pills, as well as Ella, the morning-after pill that prevents pregnancy up to five days after sex, will be dispensed through vending machines if they’re available over the counter in the near future — especially as states limit access to abortion.
“Our goal is to make it as easy as possible for students to care for their own reproductive health needs,” Cleland said. “And so being able to have a vending machine in a fairly accessible place with 24/7 access, in a building that’s easy to get into is key.”
Cost is important, too, Cleland noted. When universities agree to stock Plan B, they can control the price. Boston University recently launched its emergency contraception vending machine with $8 Plan B. It’s places in the South that will likely soon ban abortion, such as Texas, which already has the nation’s lowest contraceptive use, that need the groundswell of support to expand contraceptive access, Cleland says — the same places that are most resistant.
Zieman, the OB-GYN in Atlanta, agrees. “If conservatives want to decrease abortion, there’s one way to do it,” she said, “and that’s access to contraception. Banning abortion doesn’t eliminate abortion, but it’s been well-proven in many, many, many studies that increasing access to contraception decreases abortion.”
Jasmine works with EC4EC in South Carolina, mailing out Plan B and other resources, such as condoms and pregnancy tests, throughout the state after launching the program while in grad school. She asked to be identified only by her first name for safety concerns.
South Carolina recently joined a growing list of states that allow pharmacists to prescribe daily birth control pills, nixing the need for a doctor’s office visit. Only North Carolina and Tennessee in the South have similar laws, despite the region being poised to ban abortion now that Roe v. Wade has been overturned.
Reproductive health advocates say the legislature’s move to reduce barriers to birth control is a step in the right direction, but it’s not enough.
“There’s so much healthcare that people in the South deserve that they don’t have access to whether that’s because of transportation issues or affordability or stigma,” Jasmine said. “All of these issues are connected.”
She launched an emergency contraception hotline called Palmetto Repro last year and hopes to continue it into next year while attending med school. Folks text in and she mails out a package the next day.
Like Kakkad, she has a stash of Plan B and other reproductive health resources at home. She charges $5 to pay for shipping, but covers the costs herself if someone can’t pay.
Jasmine loves the work, but as the sole Plan B distributor in the state, it takes a toll. “There’s not really any office hours and someone could text me at any time,” she said. And they do — texts come in at all hours of the day and night, and Jasmine jumps into go-mode when they do. “Relying on the mail, I’ve got to make sure that people have access to their products within an acceptable time.” When she travels out of town, she takes a few kits to have on hand and hunts down a post office, if needed.
Though anonymity is key to all EC4EC hotlines, working on this time-sensitive solo mission helps Jasmine connect to her home state in a way she didn’t expect.
“I can make an impact by assisting people that I walk past everyday, people that I went to college with, that I met at parties, that I see in traffic,” she said, “I never know who they truly are, but I do know that I’m helping them.”
How major abortion laws compare, state by state
The last thing Tomeka Walker remembers that day was making pasta salad for a Memorial Day cookout. Despite the Birmingham humidity hanging heavy, her family was excited to celebrate a milestone: Walker was halfway through her first pregnancy.
But while getting ready for the party at her parents’ home, where she lived at the time, she started having what felt like period cramps. She later found out they were contractions. Within the hour, she gave birth to her son — who she’d already named Khairi — in her childhood bedroom. He was just over 21 weeks old and died shortly afterward at the hospital.
That was eight years ago, but Walker is still reeling from the trauma. “Some days I’m still just no good,” she said.
Despite the mental anguish she faced, Walker had few if any options after her son’s death to seek mental health care. That lack of care remains to this day, and is only getting worse. Experts say that resources are most absent in states where the need is the highest — and especially among Black mothers.
The Deep South has the fewest mental health providers per capita. Walker’s state, Alabama, is least prepared for the demand with 121 providers per 100,000 people, compared to the national average of 284. When looking for Black female therapists who can offer culturally competent care to other Black folks — something experts say helps decrease stigma and improves therapy outcomes — the pool narrows even more. Only 4 percent of the US psychology workforce is Black.
Meanwhile, Black mothers are twice as likely to have postpartum depression, but half as likely to get care for it compared to white folks, according to research from the American Medical Association. Postpartum depression is more common in Alabama and Mississippi than anywhere else in the country — where an average of 1 in 4 postpartum people report symptoms.
“Postpartum depression is just so common,” said Sinsi Hernández-Cancio, vice president for health justice at the National Partnership for Women and Families. “I also think that many of us come into pregnancy depressed, but there’s a lot of preexisting conditions, because of all the trauma that many of us have gone through, including adverse childhood events, which is also very linked and more predominant amongst people of color.”
A major source of mental health strain for Black women is the physical threat they and their babies face during and after pregnancy. Black women are more than twice as likely to experience pregnancy loss or die themselves because of pregnancy, according to the Centers for Disease Control and Prevention. And Black babies are twice as likely to die before their first birthday than white ones.
“It’s important to understand the effects of toxic stress and trauma and intergenerational trauma, and there’s every day more and more information developed around the incredible stress that people are in daily — not because of their race, but because of racism,” Hernández-Cancio said.
One the most well-documented manifestations of this racism is doctors not listening to their Black patients.
In Walker’s case, there were nearly a dozen opportunities for health providers to intervene, but one after another brushed her off, she says. About 20 weeks into her pregnancy, she started to feel like something was really wrong — she wasn’t feeling kicks like she did before. But providers dismissed her concerns. One doctor told her she was overreacting to period spotting. Another said she was exaggerating the pain. Yet another told her to “drink a Coke” to get the baby moving.
“None of them cared or sat and took the time to have conversations about what was going on with me. They were just on a mission to come in, get my info, write it down, and go on with their day,” she said.
When the worst outcome imaginable actually happened — the loss of her son — her sadness from the preventable preterm birth spiraled. She had nowhere to turn for help because there were no providers in her area who understood the intersection of her grief and her hormonal response to a suddenly-terminated pregnancy.
“I needed someone to talk to when my family didn’t understand, but the support group I found only met once a month and when I got back home, everything was the same,” Walker said. “It felt like just wasting an hour to feel good for an hour.”
Georgia and Alabama, where Walker lives, are the most dangerous places in the country to give birth. And for deaths during the perinatal period, which is the time during and after pregnancy, there are stark race disparities.
Black perinatal health advocates have long made the connection between these mortality rates, racism in healthcare, and the perinatal mental health crisis for Black birthing people.
The disparities, they say, are not biological nor fully dependent on social inequities. While Black folks are more likely to be under-insured and underpaid compared to white people, neither level of education nor insurance coverage or higher incomes protect Black women from the risk of death.
“Black women cannot educate or earn their way out of the crisis,” Hernández-Cancio said.
“We talk about the health system and we talk about economics, but underneath all those inequities is racism — it’s not a separate factor. All of these inequities in the socio-economic space and in the healthcare space are underpinned by the historic and ongoing practices and structures of the hierarchy of human value based on race.”
Shontel Cargill, a perinatal therapist and president of the Georgia chapter of Postpartum Support International, said giving birth in the South takes a mental health toll on Black folks. The statistics alone on increased maternal mortality and miscarriages increase stress levels, which are already heightened during pregnancy and can cause further complications, she says.
Cargill and other perinatal mental health providers say systemic racism in healthcare is the biggest barrier in overcoming maternal mortality and mental health care disparities. Nearly 1 in 3 Black women report being actively mistreated by hospital staff during childbirth. For Black birthing folks, it’s a bombardment of stressors, such as being ignored by providers and navigating insurance barriers, that compound over time and pose their own health risks. And those siloed health services leave patients without care, Cargill says, even among those with insurance and who know how to navigate the system.
Cargill says there’s a need to bridge the gap in services between perinatal health and mental health. “Mental health and physical health we know are interconnected. We know they play off of each other. But there’s still a tremendous gap because they stay in their silos,” she said.
Cargill came to Postpartum Support International as a patient and a provider. She credits the organization with saving her life. She calls herself a “mom of an angel, survivor, advocate” first, and a therapist second.
“I just see the need [for more mental health support] because I’ve been there. I’ve experienced the trauma.” she said. “I want to be that person. I don’t care if it reaches one mom, I don’t care if it’s two of them. I want to see change in the state.”
Though federal policy requires insurers to cover both perinatal health and mental health services as part of “essential health benefits,” states have wide-reaching control over the logistics. These benefits also only work if someone has insurance. In the Deep South — the only region in the country where nearly every state has refused to expand the Medicaid program that provides health insurance for low-income people — federally guaranteed rights don’t go far.
Despite the barriers, some progress is being made to address the dual maternal and mental health crises in the Deep South, mainly thanks to the work from women of color on the ground, like Cargill and Walker.
This year, Georgia passed a mental health parity law, which mandates local insurers cover mental health treatment at the same rates as routine physical treatment. That means state plans, including Medicaid, have to cover mental health prevention and treatments, such as anxiety or depression medications, the same way they cover a broken arm. Georgia also recently extended postpartum Medicaid health insurance to a year after pregnancy. Both of those policies were enacted federally in 2010, but without state buy-in until now after a decade of bi-partisan legislative compromises, the benefits were out of reach for Georgians.
Alabama, after years of lobbying by local health advocates, just extended postpartum Medicaid benefits, so people don’t lose their insurance 60 days after birth. Mississippi, however, has failed two years in a row to leverage rare bi-partisan support to pass a maternal Medicaid extension. So Mississippians — with the highest infant mortality in the country and one of the highest rates of maternal mortality — continue to lose Medicaid health insurance two months after they give birth. The state is now the only one in the South not to have some version of postpartum Medicaid extension in the works.
Because Medicaid covers 3 in 4 births in the state, the vast majority of postpartum Mississippians lose their health insurance just after giving birth. This is the same period when the state sees the most perinatal deaths. Most Mississippi maternal mortality happens postpartum — 86 percent — with almost half of those deaths happening after six weeks, just as their health insurance cuts off. Mental health and trauma are wrapped up in many of the state’s maternal deaths, according to the state’s Maternal Mortality Review Committee. At least 11 percent of all Mississippi maternal deaths are by overdose or suicide.
Not only do states need more providers, those providers need to be trained in culturally competent care that crosses specialties, perinatal mental health providers say.
Obstetricians need more mental health training and therapists need to understand mental and physical complications specific to the perinatal period — and not just postpartum depression, which gets the lion’s share of perinatal mental health attention, Cargill says. There is a range of complications that can be pre-existing and exacerbated by pregnancy, or arise for the first time during the perinatal period, known as Perinatal Mood and Anxiety Disorders.
“I can sit with others who may experience it as well. Not as a provider, but as a person who’s experienced it. And who looks like them,” she said. “Some of those conversations we don’t have with each other, just simply because there’s just so much stigma historically around mental health.”
In coping with the loss of her son, Walker found little support. Friends and family couldn’t relate and the few grief support groups she found didn’t understand the impact of infant loss. On top of the grief and separate — but related — growing postpartum depression, Khairi’s burial costs were swelling.
“It was the emptiest feeling ever to leave the hospital without him,” she said. “And we had to go straight to the funeral home.” The cost of a funeral for Khairi was about $5,000.
That’s why in October 2014, just a few months after losing her son, she started the Khairi and Little Angels’ Memorial fund to help Birmingham families pay for a sudden infant death and to cope with the loss. Walker raised $20,000 from her community last year.
“I’m trying to eliminate barriers to get folks into care,” she said. “I know what it’s like to not be able to pay the bill but still need help.”
Eight years after her loss, Walker has made inroads across Birmingham — connecting providers, the health department, and folks in the community to get resources into the hands of families that need it.
“We have to meet families where they are, but help move them forward too,” she said. “I want to be that person that they can turn to if they find themselves in this position because I know the type of shoes she’s wearing right now.”
Editor’s note: This story includes several references to maternal mortality, a term that is standard and common in data collection and reporting. When not referring specifically to data, we use language to include all birthing people.
Visit PSI GA and Khairi’s and Little Angels’ Memorial for perinatal mental health resources in Georgia and Alabama, or get free, confidential support through the 24/7 National Maternal Mental Health Hotline: Call or text 1-833-9-HELP4MOMS (1-833-943-5746)
Why deaths by suicide often go uncounted in states’ maternal mortality studies
On paper, one of the first deaths reviewed by Mississippi’s maternal mortality board looked like an accidental overdose. Reviewers could have stopped there, called it a tragic loss and added it to the list of the state’s 600 annual overdose fatalities, but not related to pregnancy.
But they didn’t stop there.
“We really wanted to take this as an opportunity to look at all preventable deaths around pregnancy — not just those technically caused by pregnancy,” said Dr. Charlene Collier, an OB-GYN in Mississippi and director of the state’s Maternal Mortality Review Committee, a board of physicians and public health experts tasked with studying why and how pregnant and postpartum Mississippians die.
When Collier dug deeper into the patient’s life and pregnancy, she unraveled a story that exposed a series of systemic failures. Records showed the patient had a history of depression and sexual assault as a teen. She delayed prenatal care. She also tried to quit her addiction to prescription pills, but didn’t have nearby treatment support. During pregnancy, she was arrested and locked up for drug possession and missed prenatal visits. Three weeks after her release from jail she was found dead of an apparent overdose in a friend’s apartment.
The more Collier found, the more clear it became: The woman’s substance use disorder had been preventable at multiple stages, but the systemic support wasn’t there — and it only got worse during pregnancy. And her death, at 22, was preventable too.
Overdoses and suicide are leading causes of maternal mortality. And over the last two decades, mental health disorders like severe depression and anxiety, as well as suicide, have all increased among pregnant and postpartum people, according to new research from the American Medical Association.
Yet most states don’t specifically track suicides or overdoses as pregnancy-related, despite their increasing prevalence. Mississippi is one of only a handful of states nationwide that counts suicides as part of its state-created Maternal Mortality Review Committee.
“If you dont look and don’t ask questions, you just write it off. A medical record isn’t a narrative, it’s just a checked box.” Collier said. “We’re trying to be inclusive and center the most marginalized people by prioritizing interviews to get a look at the whole person.”
Like the rest of the country, race disparities in perinatal deaths — ones that occur just before or after giving birth — are stark: Black Mississippians are nearly three times more likely to die during or after pregnancy than their white counterparts, regardless of socio-economic status. Many experts have for years pushed practitioners to face unconscious bias and systemic racism in U.S. healthcare, but it’s been an uphill battle, Collier said: “How do you measure the impact of racism? You have to listen those affected.”
Related: Pregnant Black people navigate two public health crises during COVID-19 in Milwaukee
Looking beyond the medical record informed not only Collier’s own examination of the data, but also how she presented it. She was sure to include in the first few paragraphs of her report for policymakers: “Suicides and overdoses accounted for approximately 11% of all maternal deaths.”
And the report’s subsequent recommendation: “Mississippi should increase access to mental health and substance-use services statewide for pregnant and postpartum women.” There are only two facilities in that state specializing in perinatal patients seeking addiction treatment, totaling just 44 beds.
The extent of the problem
In many ways, COVID-19 exposed deeper social inequities that have lurked for decades. Depression, for instance, skyrocketed for perinatal people.
In 2020, fatal overdoses reached record highs in the U.S., killing more than 92,000 people — a 30 percent increase from the previous record. The South drove much of the increase, particularly Mississippi, Louisiana, Tennessee, and Texas.
After stabilizing for a few years, national maternal mortality hit a record high in 2020. American women of reproductive age have the highest rate of mental health needs, all of which contribute to preventable pregnancy-related deaths, according to a new report from the Commonwealth Fund. Too, because there’s a lack of comprehensive data on perinatal trans and non-binary people, studies are likely understating the prevalence and risk of mental illness, and further undercounting pregnancy related deaths.
Already the highest of any developed nation — double that of France, the country closest behind, and 10 times the rate of New Zealand — perinatal deaths have risen about 40 percent since 2018.
While many people think of maternal mortality as a death during or just after birth, most pregnancy-related deaths occur well after birth — a sign that many of these deaths are preventable systemic failures, not caused by sudden complications. Across the nation, more than half of perinatal deaths happen postpartum with 1 in 4 occurring between six weeks and one year after delivery, a time when many have lost health insurance.
Much like cardiovascular disease, the leading cause of maternal mortality in Mississippi, suicides and overdoses are also preventable, Collier says.
Experts say the concurrent rise in maternal mortality and mental health complications not only create a perfect storm, they overlap. Though it’s hard to track, at least in part due to lacking support and diagnostics, upwards of 1 in 5 postpartum people experience depression.
Related: Coronavirus threatens an already strained maternal health system
A 2019 paper recognized depression, intimate partner violence, and substance use disorder as three of the most common risk factors for perinatal suicide. Other studies show nearly 1 in 4 reported recent suicidal thoughts.
“Is it a surprise to anyone that maternal mortality got worse in COVID? Of course it got worse. Obviously [the pandemic is] going to have a detrimental effect on mental health too, when we don’t feel safe to birth in a healthy way,” said Sinsi Hernández-Cancio, vice president for health justice at the National Partnership for Women and Family. “It boils down to: We don't have the data. Those of us in the communities know it’s a problem, but we aren’t tracking it.”
What’s being done?
Some Southern states are close to implementing rare bi-partisan policy changes. In Georgia, a behemoth bill addressing the lack of mental health insurance coverage and provider shortage is headed to Gov. Brian Kemp’s desk. Georgia and North Carolina extended Medicaid health insurance to postpartum people for a year postpartum. But in Mississippi, for the second year in a row, the statehouse failed to leverage bipartisan support to extend postpartum Medicaid from 60 days to a year after birth.
Though few states investigate overdoses and suicides as pregnancy-related, those like Mississippi that do are finding stark patterns. In California, overdoses are the second leading cause of postpartum death and suicide was seventh. Tennessee’s maternal death review tracked a 400 percent increase in suicides, from 2 to 10, in four years.
But most maternal mortality review committees either include suicide with mental health disorders, count neither, or consider these deaths unrelated to pregnancy. In a review of all southern states’ maternal mortality reports, only two investigated suicides. Five committees acknowledged it was a gray area, two lumped them in with all mental health disorders, and two — South Carolina and Louisiana — didn’t mention suicide at all.
And that inconsistency in the data collection is part of the problem, said Crystal Schiller, psychotherapist at the University of North Carolina Center for Women’s Mood Disorders.
“As an individual provider, it's easy to get focused on the patient who's coming through our door, but those are the patients with resources.” Schiller said. “There's so many gaps everywhere — it’s inaccessible to most women because it's expensive. And that leaves a huge swath of the population without access to the care that they most want, that has been shown to work.”
Despite the need, there is very little inpatient support for pregnant or postpartum people with depression: Only three inpatient psychiatric facilities for perinatal people exist in the U.S., including Schiller’s facility where she directs the inpatient unit.
Data collection will likely only be standardized if state legislatures or the U.S. Centers for Disease Control and Prevention advocate for it. Though the CDC excluded substance use disorder and suicide in its initial maternal death reviews, it later made efforts to address them, calling the association between mental illness and mortality "complicated.”
Back in Mississippi, Collier knows this. That’s why she pushes for their inclusion and more robust scrutiny of the circumstance behind each maternal death, which hopefully leads to more compassionate medical care. “A medical record is not a reflection of someone's experience. It's a reflection of what got documented by healthcare.”
Editor's note: This story includes several references to maternal mortality, a term that is standard and common in data collection and reporting. When not referring specifically to data, we use language to include all birthing people.
If you or someone you know is struggling with mental health or suicidal thoughts, round-the-clock help is available through the National Suicide Prevention Lifeline at 1-800-273-8255, the Veterans Crisis Line and Military Crisis Line at 1-800-273-8255, and the Crisis Text Line by texting “hello” to 741741.
Pregnant people in Georgia could soon have to make three separate trips to a clinic to access a common form of abortion that, under current law, they can see a doctor virtually to obtain.
A new bill making its way through the Georgia statehouse would criminalize access to abortion pills by telemedicine — a common, safe, easy way to end early pregnancies that the federal government first allowed last year.
“Telemedicine is an incredible option for people,” said Dr. Nisha Verma, OB/GYN fellow at Physicians for Reproductive Health, who provides abortions in Georgia. “We talk about abortion deserts among states, but even within the state too there are definitely these abortion deserts.” More than half of Georgians live in counties without an abortion clinic, and the new three-trip requirement would make seeking medical abortion — by pill — significantly more onerous than the traditional in-clinic procedure.
“There are people in Georgia that are having to travel hours to get to care. It feels ridiculous sometimes because literally all you’re doing is handing them a pill. That doesn’t need to be done in-person,” Verma said. “All of that creates a huge burden to care.”
Since it became an option last year, telemedicine has made abortion more accessible for patients who live in rural areas or can’t get off work, find childcare or transportation for care, she said. One in five women of reproductive age have to travel more than 80 miles to reach an abortion clinic. Other factors, like poverty, can cause people to wait longer to seek an abortion — especially in some parts of the Deep South where it’s more restricted — or forgo it all together when the barriers compound.
Related coverage: Abortion access is in jeopardy across the Deep South
If passed, the Georgia law will ban telemedicine abortion access by requiring in-person pill prescription and three separate visits to a clinic. Georgia already requires a 24-hour waiting period for abortions, and the bill mandates an additional in-person follow-up visit.
Despite the new federal rule, most Southerners don’t have expanded access to abortion pills. Currently, Georgia is one of only three Southern states — along with Florida and Virginia — that allow telemedicine abortion. As the fate of abortion access awaits the Supreme Court’s decision on Mississippi’s 15-week ban, most Southern states have preemptively restricted access to abortion pills by mail.
Overall, 19 states have restrictions on accessing medication abortion — prescribed in two pills, mifepristone and misoprostol — through telemedicine, despite its efficacy and safety.
Though the number of abortions overall has decreased in recent years, medication abortions have almost doubled to account for nearly half of all abortions, according to the U.S. Centers for Disease Control and Prevention. As access restrictions have spread across the South, these states in particular have seen surges in medication abortions.
In Georgia, pills went from accounting for 1 in 5 abortions in 2014 to half in 2019. In Mississippi, 70% of all abortions happen by pills — up from a third in 2014. Both Georgia and Mississippi have 6-week abortion bans on the books, which are blocked at the federal court level while the Supreme Court debates the fate of Roe v. Wade.
Even before the FDA loosened telemedicine abortion rules, people self-managed medication abortion through online ordering systems and mail delivery — COVID-19 and increasing abortion restrictions further popularized the process.
Related coverage: Could the coronavirus make telemedicine abortion the new normal?
“Telehealth is a real lifeline for access to medication abortion should states ban abortion,” said Elizabeth Nash, who researches state abortion policy at Guttmacher Institute. “Right now we are in a place where many states have banned telehealth for medication abortion, but where it is potentially available, it’s very important to maintain that … access to abortion care. And when access is curtailed, having access to telehealth is a real benefit.” Other Southern states that already ban telemedicine abortion, such as South Carolina and Alabama, currently have legislative bills that would take their restrictions a step further to further restrict or completely ban medication abortion. Both states also have concurrent bills that would ban all abortions.
Advocates reiterate, though, that abortion is still legal across the U.S. Despite statehouses’ efforts to limit access, most state bans — except for the 6-week law in Texas — are currently blocked at the federal level.
Like most abortion restrictions, experts say the Georgia bill is not based in science or standards of care, but aims to further limit abortion access in the state and region.
“It’s just really frustrating,” said Verma, the provider in Georgia. “The law’s telling me that I need to do things that are not based in science or data or evidence, and are not best for my patient.”
Amy, an ICU nurse, is considered a veteran in her busy hospital in Athens, Ga. As older nurses have hemorrhaged from the unit during the pandemic, less experienced nurses often look to her for guidance on things like how to fix a monitor, manage a drug dosage, locate extra supplies, or decipher a doctor’s handwriting. Though this informal leadership can be a heavy burden as the unit grapples with ventilated COVID-19 patients, it doesn’t come with a title or pay boost.
Amy is just a few years out of nursing school herself. She’s doing the best she can, she says, but after operating at near constant-crisis for two years now, her limited experience can only go so far.
“It’s babies teaching babies. With five years, I’m one of the most experienced staff,” said Amy, who asked to be identified by a pseudonym and the hospital where she works not be named for fear of retaliation from management, which she says has happened when other staff spoke to journalists. “Every shift, we’re just barely making it.”
What Amy is managing in her ICU during the pandemic has been daunting to seasoned nurses with two or three times her experience: overwhelming patient loads caused by spiking virus case rates, shifting protocols, thin staffing, and widespread burnout, exacerbated in some pockets in the South stemming from vaccination resistance. “We are missing care points that used to be a standard, but that we haven’t been able to do because we don’t have the staff to pay attention to that,” Amy says.
Many of the more experienced nurses have left their jobs, if not the profession altogether. As the Omicron hospitalization surge has crushed hospitals across the country, in Athens — which serves as a medical hub for 17 surrounding rural counties — her hospital has had periods of being too full to accept new patients. Not because there aren’t enough beds per se, but because there aren’t enough nurses to staff them.
Amy’s reality is supported by new data. Since the pandemic began in spring 2020, unemployment has soared for nursing positions — in part because of early-pandemic layoffs, but mostly due to nurse resignations. Even before the pressures of record-breaking hospitalizations, the nursing industry was already facing high rates of burnout that disproportionately impacted female healthcare workers.
Over the last two years the number of registered nurses nationwide dropped by 100,000. For licensed practical nurses and nursing assistants, the decreases were 25,000 and 90,000, respectively. People of color left the field at disproportionately high rates.
The South has been hit particularly hard. Mississippi lost 2,000 nurses in 2021; hospitals in Tennessee had 1,000 fewer staff compared to the beginning of the pandemic; Texas recruited 2,500 nurses from outside the state, though it wasn’t enough to meet demand; and, Louisiana had over 6,000 unfilled nursing positions open before the Delta variant caused a surge in cases, just as Hurricane Ida was hurtling toward the state and displacing hundreds of healthcare workers last September, according to data from the American Nurses Association.
The problem has only gotten worse as the Omicron variant has pushed COVID-19 hospitalizations to record highs across the country, which have just recently begun receding in some parts of the South but are still hitting daily records in others.
There was already a nationwide nurse shortage. Compounded by the pandemic, the effects of that shortage are magnified in the South, by factors including disproportionately high rates of chronic illness, persistent poverty, low-wage jobs, and statehouse-driven health policy decisions.
Amy says the result is a team of younger, inexperienced staff who are already at risk of burnout themselves while their compassion fatigue takes over as shifts become Groundhog Days of death and hopelessness. And worst of all, she says, it’s preventable. At her ICU and across the nation, almost all of the sick and dying COVID patients are unvaccinated.
Sicker patients — both unvaccinated patients with COVID, and those who delayed care during the pandemic and now need a higher level of care — have filled ERs for too long, overflowing into hallways and ambulance bays, spilling into all aspects of health care.
“I know exactly what I'm walking into every day — a COVID-land with no support,” Amy said. Pre-COVID, her ICU shifts were challenging, but there was always hope. After nearly two pandemic years, the energy from innovative treatments and the adrenaline of racing toward a cure is gone. “I know exactly what's going to happen. All of them are going to be intubated, vented for weeks, and some will die long deaths,” she said. “It’s become monotonous and taken out a lot of the joy.”
Every one of the dozen nurses The Fuller Project and Reckon interviewed for this story pointed to ongoing hospital pain points that, though present before the pandemic, have been exacerbated by month after month of constant crisis.
There are simply too few nurses to care for the surging need. “We’re sprinting every day,” Amy said, “And you just can't maintain that.”
'No raises, bonuses, or hazard pay'
On top of the mental strain, the stubbornly low wages many receive feel like “a slap in the face,” says Brittany*, who recently left her position in Mississippi for a higher-paying traveling agency position. (She asked to be identified by a pseudonym for fear of retaliation when she returns to her home hospital in Jackson.)
Nurse pay has remained relatively flat for the last decade, and only ticked up slightly during the pandemic, according to recent Health Affairs research, but least so in the South where care has always demanded more. Mississippi staff are paid among the lowest in the country — with a $28.67 average hourly wage (behind only South Dakota, at $28.73) — about $10 hourly shy of the national average.
“The hospital won’t give us raises, bonuses, or COVID (hazard) pay,” said Brittany, who is currently working in Louisiana through the agency. “And then you have a neighboring state who’s offering $126 an hour and a $1,000 stipend to pay for housing during the week, versus your $30 job at home.”
“I don't care about the healthcare hero signs anymore because the hospitals have shown that they don't care about us. If you really think that we are the heroes that you say we are and we are a vital part of the healthcare community, then pay us what we’re worth.”— Brittany,* nurse
Amid these pay gaps, expressions of gratitude, she said, have started to ring hollow. “I don't care about the healthcare hero signs anymore because the hospitals have shown that they don't care about us,” she said. “If you really think that we are the heroes that you say we are and we are a vital part of the healthcare community, then pay us what we’re worth,” she said.
Instead of higher pay, the new COVID wave has been met with fewer staff, who are asked to do more under constant crisis conditions and peak hospitalizations.
The underlying causes of financial stress in the hospital system predate the pandemic. For one thing, Mississippi has among the highest rates of uninsured people in the nation — four of the five states with the most uninsured people per capita are in the South. People without insurance are more likely to seek care in emergency departments because they lack other options.
For another, over the past 10 years, Southern states have seen the most hospital closures — in part due to decades of providing uncompensated care — so staff see a tighter, sicker squeeze on resources. Across the country the Southern states, Texas, Tennessee, and Georgia lost the most hospitals.
Mississippi is not far behind. Because its hospitals are so taxed, Mississippi in early January entered crisis standards of care — an emergency intervention tool employed by the state health department to spread the burden across hospitals by revolving new ICU patients to different facilities around the state. It’s meant to be short-term, but is still in place a month later. Mississippi has among the lowest vaccination rates, stalled at 50%, and has seen the highest death rate across the pandemic.
Hospital administrators and public health advocates in this region have long said they need federal and state financial help to prop up their hospitals and health systems. Expanding Medicaid allows people with low incomes to sign up for federal health insurance, and research shows it helps hospitals stay open because they’re reimbursed for care that would otherwise be given for free.
Studies also show having more people insured not only saves states money, but also saves lives by expanding access to preventive care, like cancer screenings, and helps people get acute care faster when it’s needed. Of the 12 states that have not expanded, almost all are in the South.
Capacity a misnomer for staffing
Meanwhile, most Southern state policymakers have done little to address the issues.
Quite the contrary: Legislatures, particularly in the South, have slashed public health budgets, and with it staffing, over the last decade. Due to state budget cuts, local health department spending has plummeted by almost 20% since 2010 and staffing dropped at the state and local level by nearly 40,000 jobs.
Despite generally having higher need — more poverty, chronic illness and uninsured folks — cuts have been deepest in the South. Louisiana’s health agency spends the least per capita: $32 per person; at $37, Tennessee isn’t far behind. Delaware spends the most per person, just above other Northeastern states, at $263.
These spending cuts have exacerbated nursing shortages, not just piling more responsibilities on those who have stayed, but also compromising care, nurses say.
No federal law regulates the number of patients a nurse can be responsible for at any given time, known as nurse ratios. Standards vary by unit and patient need, but American Nurses Association standards of care and research recommend that each nurse be responsible for one patient in an ER setting, two in an ICU setting — though research shows that COVID patients necessitate one patient per nurse, and at most, five in a rehabilitation setting.
Texas is the only Southern state to address nursing ratios by law, mandating hospitals have committees to standardize staffing ratios. (California is the only state nationwide to require a minimum nurse ratio on every unit.)
In Mississippi, Brittany points out that the growing ratios are dangerous for nurses and diminish patient care. “In some cases the hospital tries to present it to you as about patient care — ‘it's for the best’,” she said. “But is it really for the best if I’m supposed to have a 1:2 patient ratio and you have a third patient on a vent? Are they really getting the care?”
Brittany says messaging that hospitals are short on available beds clouds the reality. “The hospitals are not running out of beds, they're running out of nurses,” she said. “You can transport patients all day long and put them in rooms all day long, but if you don't have a nurse to carry out doctors’ orders, what good is a bed going to do for a patient?”
In early January, South Carolina hospitals experienced some of the worst shortages in the nation, with 36% of facilities reporting “critical staffing shortages” — a term not defined federally, but left up to internal policy and facility needs. In 2018 South Carolina already had the fewest nurses per capita, at 7.9 per 1,000 residents, one of just four states to have a ratio lower than 10 per 1,000, including Texas.
In North Carolina, where the nurse ratio is slightly better than the U.S. average at 12 nurses per 1,000 residents, an interactive tool is being used to model current and future nurse shortages across the state. Emily McCartha, a researcher at University of North Carolina’s Sheps Center for Health Services Research, who helped develop the tool, says the data will start pointing toward policy solutions. “We will also have to work on retention of current staff and potentially coaxing folks that have exited the field to return,” she said.
‘Without nurses there is no health or healthcare’
In the meantime, many nurses in the South say they just want to be heard and their plight recognized. But even that can be elusive.
Last September, Ernest Grant, president of the American Nurses Association and a North Carolina-based nurse by trade, sent the country’s top health official an urgent letter asking for the national nursing shortage to be declared a public health crisis — and for funding to be allocated to help.
In the letter, Grant told U.S. Department of Health and Human Services Secretary Xavier Becerra, “ANA is deeply concerned that this severe shortage of nurses, especially in areas experiencing high numbers of COVID-19 cases, will have long-term repercussions for the profession, the entire health care delivery system, and ultimately, on the health of the nation.”
“Without nurses there is no health or healthcare. We are the backbone,” Grant said in an interview with The Fuller Project and Reckon. “But as we continue to drive more and more away, that care system is going to implode on itself if it hasn't already in some places that are implementing crisis care standards.”
In his letter to Becerra, Grant pointed out that Southern states have among the worst nursing shortages.
Grant says Becerra has yet to respond. At publication time, HHS had not replied to queries about it from The Fuller Project and Reckon.
Meanwhile, young nurses like Amy, the ICU nurse in Georgia, feel stuck. With $100,000 in nursing school debt, leaving the field and returning to bartending, which she did before becoming a nurse, isn’t feasible. For now, she’s resigned to cope with what comes her way in the ICU.
“This doesn't have to be this way. And this isn't a situation we’ve electively signed up for. I’m not a martyr, I don’t want to be a martyr,” she said. “I also think it got the hospital out of (accountability) when we would be complaining and they were like, ‘But look at all the community support you have and look at all the little thank you, nurses notes from first graders.’ It’s not a solution.”
As the nation focuses on abortion bans in Texas and Mississippi now before the U.S. Supreme Court, some advocates in the South are frustrated that their dire warnings — that abortion restrictions in the region would inevitably reverberate throughout the country — went unheard for so long.
Now those advocates argue that lack of action on laws such as Mississippi’s abortion ban has invited the most significant challenge to Roe v. Wade in history. Further, they say, if Mississippi is successful in defending its abortion ban, that decision will touch off a domino effect, starting in other Southern states and eventually spreading across the U.S, including places where abortion is currently accessible.
Even if the court leaves Roe v. Wade partially intact, access in major cities such as Atlanta, Birmingham and New Orleans — historically beacons of access in the South and located in states where out-of-state residents make up nearly one-in-five abortions — will be at new risk, as all three states face their own bans that are tethered to the fate of the more high-profile cases.
In the meantime, as justices mull arguments from Mississippi and Texas, advocates are busy clarifying falsehoods that abortion is now illegal, fighting stigma, and reducing barriers to care — with an eye to not only healthcare but also to the economic, social, gender, and racial implications that accompany reproductive rights.
“Our fight is not solely about abortion — it’s abortion and many other things. If we can’t meaningfully decide to not be pregnant, we can’t meaningfully decide to be pregnant or to become parents,” said Roula AbiSamra, state campaign manager for Amplify GA, a collaborative of reproductive rights and justice groups in Georgia. “And I continually come back to that positive vision of what we would have if this world and if this state were free — and it would not look like an abortion ban. It would not look like abortion for some of us but not for others.”
Though laws do vary state by state, it’s hard not to see abortion rights across the Deep South as, in many ways, interlinked. The 2021 Texas law, which effectively bans abortions after six weeks of pregnancy, followed and largely built off of a 2019 Mississippi law that did the same thing. At the time, abortion access advocates in Mississippi warned the ban — then the strictest in the nation — would soon be duplicated by neighboring states, further thwarting access in the already patchwork region.
Outcomes in both the Mississippi and Texas cases will determine how other states, particularly those hostile to abortion access in the South and Midwest, legislate restrictions. But advocates also point to the reality that has long plagued this region and only gotten worse over the last decade. Conservative state legislatures’ near-constant and increasingly restrictive efforts to curb abortion access have created a landscape where Southerners’ ZIP codes and financial stability largely determine whether they can access abortion.
In Georgia, a federal appeals court recently deferred judgment on the state’s 2019 six-week abortion ban until the Supreme Court weighs in on Mississippi’s 15-week ban. When oral arguments begin in the Mississippi case Dec. 1, it will be the first time the high court hears a pre-viability ban since Roe v. Wade, carrying heavy implications for access in Georgia.
“The appeals court made explicit that what happens in the Mississippi case is relevant to what happens here,” AbiSamra said. “We know this, we have been saying this — Mississippi is asking for Roe v. Wade to be reconsidered and overturned — but I don’t know if people understand this is a national-level machine.”
‘Screaming from the rooftops’
Advocates in the South have been sounding the alarm for some time, but not everyone has heard it — until now. “Folks on the ground, especially reproductive justice activists, have been kind of screaming from the rooftops for a while now,” said Quita Tinsley Peterson, who co-directs Access Reproductive Care-Southeast, the only abortion fund serving Georgia.
Peterson said the bans in Southern states explicitly target marginalized people: “It’s clearly a coordinated strategy by folks who are not only anti-abortion, but anti-their own enemies, which often look like Black and brown people, queer and trans folks, and those in rural areas.”
Access has never been robust here, but restrictions have compounded and dovetailed to unprecedented levels that risk turning the whole region into an access desert where the closest clinic is hundreds of miles away — already the reality for most in Mississippi and Texas.
Soon after the Texas ban went into effect, research showed the distance to a clinic for most Texans increased from about 35 miles to nearly 500 miles round-trip, according to data from Guttmacher Institute. And the two states closest to most Texans, Louisiana and Oklahoma, have their own restrictions that require multiple-day trips, unfeasible for those who can’t afford to travel, take time off work or find childcare — disproportionately women of color living in poverty, especially in rural areas.
By early November — two months after the ban took effect and just as the Supreme Court was hearing expedited procedural arguments — further research showed the ban was having its intended effect. Abortion access in Texas dropped by half, and subsequent wait times in neighboring states ballooned, compounding negative impacts across the region.
It took a while for supporters of reproductive rights to wake up to what was happening to access across the South, said Dr. Bhavik Kumar, a family medicine physician who provides abortion services at a Houston Planned Parenthood clinic. “What happens in Texas doesn’t stay in Texas. Other states are copying these laws — this is a pattern for access across the South, as well as in the Midwest and these restrictive states,” he said. “It just didn’t feel like folks were grasping it or perhaps even folks within the movement, honestly.”
Kumar also points to other countries, like the recent death of a pregnant woman in Poland, to foreshadow what he fears is a not-so-distant southern abortion landscape. “We don’t need to wait to see what happens with the Mississippi case and when abortion is slaughtered throughout the South and the Midwest and we don’t have access. It’s already happening in other countries,” said Kumar, who also serves on the board of Physicians for Reproductive Health and recently began practicing in Louisiana in the wake of Texas’s ban.
Though the Georgia six-week ban was immediately blocked in federal courts and technically never took effect, advocates feel its chilling effect on access. AbiSamra says Amplify GA’s coalition partners have battled misinformation and confusion for months, fielding calls from pregnant people wondering if abortion is still legal in Georgia.
Advocates across the sprawling region all separately pointed to the importance of local elections and community mutual aid, like abortion funds. AbiSamra noted that statehouses are the first line of defense against restrictions. In Georgia, every seat of the state legislature goes up for a vote every two years. “So as constituents we’d better start asking what elected officials need to do to earn our trust in 2022,” she said.
She also points to national protections, such as the Women’s Health Protection Act passed by Congress in September that would codify a legal right to choose abortion and make it harder for states to enact bans.
Meanwhile, in Louisiana, just last year abortion advocates saw a narrow win when the Supreme Court overturned an admitting privileges law that threatened to close all but one clinic across the state. But now advocates feel whiplashed as the state’s 15-week ban, which is tethered to Mississippi’s, is back in front of the court.
“Louisiana is literally the middle child between what’s happening in Texas and Mississippi right now,” said Michelle Erenberg, executive director of Lift Louisiana, an New Orleans-based advocacy organization that works on women’s health policy. “I think a lot of the national coverage rightly has focused on the devastating impacts of the current law in Texas and also the case in Mississippi that is on the horizon. But both of those stories have a dramatic impact on Louisiana.” Erenberg also pointed out that just last year, voters passed a state constitutional amendment banning abortion if Roe v. Wade is overturned.
And in Alabama, the state legislature passed a near-total abortion ban in 2019, but it never took effect after being quickly blocked by a federal judge. State officials declined to appeal noting lack of precedent, but said their ultimate objective was to move it, or similar cases, to the Supreme Court — as now is the reality.
What’s to come
The Mississippi 15-week ban is limited to one legal question: whether all pre-viability bans on elective abortions are unconstitutional. If the Court agrees with Mississippi that states can ban abortion before about 24 weeks — which, until the Texas six-week ban, no state had successfully upheld in federal court — states will have free rein to pass stricter and stricter bans.
If the Court weakens Roe, but upholds other precedents like Planned Parenthood v. Casey and Whole Woman’s Health v. Hellerstedt that use the “undue burden” standard to gauge abortion restrictions, conservative states with patchwork laws are likely to continue challenging the standard and winding concurrent bans through federal courts, similar to the current landscape.
If the Supreme Court overturns Roe v. Wade, at least 18 states are expected to immediately ban abortion. That would mean an entire swath of the country without abortion access — stretching from Texas across the Southeast up to Missouri, with North Carolina likely the only Southern state to not immediately ban or severely limit access. It’s a reality abortion advocates in the South have been facing one way or another for years.
“Access is not just being thwarted or impeded in Texas because of what’s happening there now, or Mississippi. There’s a whole region of the country that is and has been struggling to secure and protect abortion access over the last two decades or more,” said Erenberg of Lift Louisiana.
Peterson, in Georgia, said supporters of reproductive choice in other parts of the country have been ignoring Southern advocates for years: “It’s not lost on us that people in coastal cities and people in D.C. are like, ‘Oh my gosh, there’s an issue!’, when we’ve been screaming for a long time.”